Provider Demographics
NPI:1437490505
Name:KIM, PETER M (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MIN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PSC 444 BOX 2412
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96297-0025
Mailing Address - Country:US
Mailing Address - Phone:109-541-8312
Mailing Address - Fax:
Practice Address - Street 1:549TH HOSPITAL CENTER/BDAACH
Practice Address - Street 2:UNIT #15245
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:US
Practice Address - Phone:315-737-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414415122300000X, 204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery